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HomeMy WebLinkAbout016-1070-20-100 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER M ,4,V ADDRESS ~2 6J - /3p 7`-~i A ✓ e G1- eAl A-10 G~ /7x SUBDIVISION / CSM# O/d ~2 O LOT # SECTION Y_T YQ_N-R_Z-,-5"-W, Town of gLeNLc~DDd ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM S ---0- a 4. 'Z 13 T~~ / R 1 q3 Ha WS-6 4V INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. J BENCHMARK: rO /0 O /C b L O d /i S- O N ~A M e/V 7` ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: 41 R Liquid Capacity: /A-V-V Setback from: Well House Other Pump: Ma cturer Modell _ Size Float seperation Ga cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length ~O Number of trenches Distance & Direction to nearest prop. line: Setback from: well House Other ELEVATIONS Building Sewer ST Inlet; ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: ~ i PLUMBER ON JOB: f le', LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Per it o,~~ier's 1~ e G ❑ City ❑ Village Town of: State Plan D o CST BM Elev.: C C __TInsp. BM Elev.: BM Description: Parcel Tax No^ 1 A94009,19 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet Vent TANK TO P/ L WELL BLDG. A irIto ntake ROAD Dt Inlet Air Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft oss Head Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Di;. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION TypeO CHAMBER Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION : GLENWOOD 33.3 0v 91 , NE , NE, 130TH AVE. ear _ Plan revision required? ❑ Yes ❑ No Use other side for additional information. I F SBD-6710 (R 05/91) Date Inspector's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ®ILHR SANITARY PERMIT APPLICATION COUNTY , TO a`HR In accord with ILHR 83.05, Wis. Adm. Code s d / STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than a a 4 (/o5 8% x 11 inches in size. ❑ Check If revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION N Y4Y4,S T3©,N,R i"or)W PROPERTY OW R'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER,;_„ SUBDIVISION NAME OR CSM NUMBER 6~eN 400,1 C i w~^ a/3 T/-s y II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ State Owned VILLAGE ; ~r~B/S/LlJOOo,1 ❑ Public 1@ 1 or 2 Fam. Dwelling-# of bedrooms o? A L M R ) III. BUILDING USE: (If building type is public, check all that apply) G / /D ]U 2 e~," !DO 1 ❑ Apt/Condo !b 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑ New 2. ❑ Replacement 3.E1 Replacement of 4. ® Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ® Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION Feet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No tamps) MP/M-IMM No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): F #w 170 6Leiv w .0,0 a/ IX. COUNTY/DEPART ENT USE ONLY Disapproved Sa itary Permit Fee (Includes Groundwater a e ssue Issuing Agent Signature (No Sta ps) Approved ❑ Owner Given Initial Surcharge Fee) Adverse D rmin do X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will' be applicable. 3. All revisions to this permit must be approved by 4he permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. 11. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. Vl. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill! in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8'f x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) SOIL AND SITE EVA EPORT rage or II.HR in accord with ILHR 83.05, Wis. Adm. Code COUNTY , Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but S~ O l not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION 619 //1;9 /V GOVT. LOT IV E 1/4 1/4,ly T 30 N,R /„5 fkr) W PROPERTY OWN 'S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # ;2 7 CITY, STATE / ZIP CODE PHONE NUMBER 0CITY OVILLAGE ®fOWN JNEAREST ROAD t'llzyl i 0%3(7ls) = 3 G~ e w o o-01 G Gv o fAl [ ] New Construction Use [ I Residential I Number of bedrooms [ ] Addition to existing building Replacement [ ) Public or commercial describe Code derived daily flow ADD gpd Recommended design loading rate _bed, gpd/ft2 , g trench, gpd/ft2 Absorption area required /S`aO bed, 1112 le_" trench, ft2 Maximum design loading rate ~~bed, gpd/ft2 ,trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design / site considerations Parent material G,L A / L / L Flood plain elevation, if applicable a/ A ft S =Suitable for System CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem 0 S ❑ U [IS O U [IS [1U 0S O U O S O U 0 S O U SOIL DESCRIPTION REPORT pth Dominant Color Mottles Texture Structure Consistence Bots" Roots GPD/ft ftD Boring # Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench s Af Z' 14 ✓F G lo, /L s6~ -lax Ground 0 5~ 6 c M~~ w 2 elev. M f,/oft. Q SfOS y 141 Depth to limiting factor 7 9~z Remarks: Boring # .h Ground elev. ft. Depth to limiting factor Remarks: T Name:-Please Print Phone: h rAddress. 6V e/V k ea d i l' {t/ jr gnature: / Date: J 9 CST Number: ~ MAAL~ i 71F - - I t---i : i qrl 29iA, UNWIWWVQC~ ~-2- k ~~re - - - - - - - _ - - - IvI 40 a_ Q f ~`,~eN -s - !I ~ i - e I ~ I u eI i ~I I i - - I ~ , I I I i I r I i ' ~ ICI ~ - I--- I I i ~ f- - I I I I i I I III! II I ~ ' I F i - - -i - - I 1 I I I I ~ I ; L I 1 ! ~ ~ fi I , I I~ I I a ~~i r - T r } i i Lumber • Building Materials Lamperts i j I I I. i i I i I I I i I i ; j_ 1 j - j L _ I i • 1 I I' I I I_ f I , I 1 I ! - ( 1-17 t I , I~ I ! I ~ l l_ i , L _ I I ~ I e I I ! I of a I I I i i I I I I t I i ~ ' ~ R I ~ ! I ~ I , I ' I I I j I I VIZ I j , ! } ' i ' i I I I p i ~ I• j I I I I , I , I j , ; I ' I I r r II ~ , 3 i j I~ I I i_ I ~ I I j I O I I I I I r ' " ~ 3 L I i, I L_ V) , Z ( I too. l I , I I i I I I 1 o I . ' I P-» j j i I I II I i I d ' ~ I ; I I I I I I I I ! I i i i , vl I I _f I I I , ~ I I I { I i I I i I , I I I i I j I I ' j i I I. i s~~adzu~ s/euaje/N 6Qp!n8 . aagwn- i L NOV 2 51992o- 492137 JAMES n'r.c)NN`~Es L ~ ~J R~;;;o; ~ . )e WI St. Croix CO.. M I1FIED SURVEY MAP DONALD AND JULIE FRIEBIFS 'p Part of the Northwest 1/4 of the Northeast 1/4 of Section 33, Township 30 North, Range 15 West, Town of Glenwood, St. Croix County, Wisconsin. O Indicates 1" x 24" iron pipe weighing 1.13 lbs./lin. ft. set. N 114 COR. SEC. 33, T 3ON, 915W, NE COR. S£C. 33, r30N, R 15w, /COUNTY SURVEYOR'S M0N.1 /COUNTY SURVEYOR'S MON.) UNPLA TTED LANDS -~T N L/ N E NE 114 N "9. 39' 33 "E 26f.6.71',, 466.70' b 725.41' q TH AVE. /434.60' M~ S 89. 47' 40 W 466.70' ^ W 2 \ k h _ - HIGHWAY SETBACK LINE 0 Z 2 ° LOT Z e e Q ;W Q a S. 000 ACRES -j C j J O 217, 809 S0, FT. Z h 4.569 ACRES EXC. ROAD R. 0. W. m CA Z R LU ^ h /99, 021 So. F7. I Q DRIVEWAY = 41 p, Q N N ~ ~ 3 a ~I h Q I N N Q W aC -j Z i p fn O Q. I 2 11 BILE HOME ~I u M ~ I Q SEP7/C % V W J h tk GARAGE Q C S 89 ' 39'.73 "W 466.70' UNPLA TTED LANDS ~~~tM SCALE /oo' N ~5C0F O 25' 50' /00' 200' 300' •~..•a••••.,, LAUR C ~r9n~WM RH ~Ze Z~+ i 13 i is N ER FALLS, f 4 w Dated: October 5, 199? Revised: November 1992 , • WISC. ..r• Q. This instrument drafted by Laurenc'~M~i LANO SJ,~.•` Owner's Address : rs'J 2 5'9Z 1284 300TH St. \~J9 Glenwood City, WI .54013 Laurence W. Murphy cRolx COUNTY Registered Land Surveyor ~4^.iti=I and . 4 Coma' itteo Laurence W. Murphy Registered Land Surveyor r' --Lot recorded Vol. 9 Page 2567 i+l 30 days of Certified Survey Maps ,v ai. dat© St. Croix County, Wisconsin shall be SFEET 1 OF 2 rkjp, & void CEfiTIFIED SURVEY MAP DONALD AND JULIE FRIER Fri Part of the Northwest 1/4 of the Northeast 1/4 of Section 33, Township 30 North, Range 15 West, Town of Glenwood, St. Croix County, Wisconsin. Description: That certain parcel-of land located in the Northwest 1/4'of the Northeast 114 of Section 33, Township 30 North, Range 15 West, Town of Glenwood, St. Croix County, Wisconsin, more fully described as follows; Commencin?" t the North 9 ~ 114 corner of said Section 33, thence N 8903913311B-tassumed bearin anJt g Fja"`tNor_th line of the Northeast 1/4 of said Section 33) a distance of 725.41' to the POINT-OF BEGINNING, of the parcel to be herein described; thence continue N 89039'33"E 466.70' on said line p , thence S 00 2012711E 466.701; thence S'89 39'33"W 465.701; thence N 00020'47"W 466.70' to the POINT OF BEGINNING, contain}ng 5.000 acres, being subject to easement over Northerly portions of said parcel for town road purposes as shown on this map and also being subject to easements"of record. r: Each parcel shown (1 this map is subject to State and County laws, rules and regulations (i.e., w lands, minimum lot size, access to parcel, etc.) Before purchasing or developi`rig`ann parcel contact the St. Croix County Zoning Office for advice. State of Wisconsin) County of Pierce) I, Laurence W. Murphy, Registered Land Surveyor, do hereby certify that by direction of the Owners, Donald and Julie Frieburg, I have surveyed and divided the lands as shown hereon in accordance with official records, Chapter 236.34 of the Wisconsin Statutes and the Ordinances of St. Croix County and that this map and description are a true and correct representation thereof. ♦♦tit1111/1~ This instrument drafted by Laurence W. Murphy C~ rr LAURENC = m W M PH °C : cm S 13 Dated: October 5, 1992 ~4 ~ N E fA Ll3 /Revised: November 25, 1992 i~~ • Q~ •LAND NUV 2 5 92 ~~Illl/~t• Laurence W. Murphy 'r.At71X COUNTY Registered Land Surveyor . .;,~s~h~.••.ri+sivo Plunnk►c~ and r r -,l t-tic riled Vol. 9 Page 2567 30 days of Certified Survey Maps dAto St. Croix County, Wisconsin ovaihaflb~ n-41 R void STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/ Gr~~I D~ f1 )V MAILING ADDRESS o2 7,61.,7 1_70 I`X 14 0 ~9,~~i(/G~ o 0 0/ C PROPERTY ADDRESS S/4 m& (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION IYZ~: 1/4, 1/4, Section 3T__.Z~2__N-R W TOWN OF G~e/S/ Gvoo 0 ST. CROIX COUNTY, WI SUBDIVISION / LOT NUMBER CERTIFIED SURVEY MAP 9°2 j PAGE,, rp~LOT NUMBER VOLUME Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE: L St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property c kA /,;Z MA A/ Location of property 1/4 /E 1/4, Section -Z? TAN-R W Township_ ~91N4,,ad a/ Mailing address Address of site "Al z° Subdivision name Lot no. Other homes on property? Yes( No Previous owner of property 2%.X//Lob Total size of property Total size of parcel Date parcel was created / ~7;z Are all corners and lot lines identifiable? Yes _#P No Is this property being developed for (spec house) ? Yes ___X_No Volume UI and Page Number 1109- as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. 6„f' y 7 , and that I (we) presently own the proposed site or the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. y9~3#,7 7/0 Si natur p icant Co-Applicant Date of Signature Date of Signature VOL 998` CIE .112 THIS SPACE RESERVED FOR RECORDING DATA oocuMErvT NO. WARRANTY DEED STATE BAR OF WISCONSIN FORM 1982 496347 - = RLUSIEW8 OFFICE ST, CRON CO., WI r A.QrnaI-d._E_,_._F.r?~.e-burg.._and..J.ul_ie.._A•.--.Frieburg.,-------------- Re: d #:,r Recott! Uuaban-d__and---w.i.t.e.._a-s ---JQi-1xt---tenan_ts................................. MAR 2 3 1993 F Ut 11:00 A. . i conveys and warrants to C--•--r--a--i- A. Ohma--n-•, a sing--le e r s o n '~^v. P-. ~~Pe.'Vster of Deed3 - - - - - - _ RETURN To Rivard Law Office O Box - P. 9 Glenwood City WI 514013 the following described real estate in ._._St. Cro i x Y~-_--___---___ Count----- - State of Wisconsin: Tax Parcel No_ Ii Part of the Northwest One Quarter (NW4) of the ii Northeast One Quarter (NE-4-) of Section Thirty- three (33), Township Thirty (30) North, Range Fifteen (15) West, more particularly described as follows: Lot One (1) Certified Survey Map in Volume Certified Survey Maps, page 2567. ~r~ li This __is- --not - homestead property. xigoo (is not) Exception to warranties: Subject to easements and rights of way of record, county and municipal zoning ordinances, if any. Dated this c~c day of/- 19 93 - ------(SEAL) --.Y' -------(SEAL) Donald Fr-i_eb.ljrg------------------ . rg-------------------- i --------------------------------------------------------------•----(SEAL) (SEAL) * * I! AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ss. l S t. Croix County. authenticated this ________day of___________________________ 19.93 Personally came before me this 20th______day of -Feb.ruar.y 19.93_- the above named - _ - *_____Francis___X_.___Rivard Julie A. Frieburg TITLE: MEMBER STATE BAR OF WISCONSIN Donald E. Frieburg - - (If not, r authorized by § 706.06, Wis. Stats.) to me k n to h~t~le ' rson- __=_S~i',n.. ;who executed the fore ng nstrurl nt 2dge the same. c; t ; II ; , THIS INSTRUMENT WAS DRAFTED BY Francis X. Rivard a nice_';M. ,3' l.._p Glenwood City WI 54013 Not r Public .....:_._sro_ix_ ` y, Wis. i . G--,~-----:,Count (Signatures may be authenticated or acknowledged. Both My ommission is pepinane ~i~3£i riot, state expiration are not necessary.) :IF date- --------------1-112-Q------------------------------, 19.94__.) 'Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. FORM No. 2 - 1982 Milwaukee, Wisconsin